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Case files neurology Flashcards

1
Q

65 y/o R handed man w/ 20yr h/o tremor w/ posture/intention tremor. similar in mother and daughter. beer reduces tremor
Dx?
Next step?
Management?

A

Dx: benign essential tremor
Next step: MRI brain and spine
Management: primidone, propranolol

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2
Q 
40y/o in ED for inappropriate behavior/confusion. fidgets for several years w/ choreiform movement. alert but easily distracted. hyperreflexic everywhere
Dx?
Next step?
genetic basis?
Management?
A

Dx: Huntingtons dz
Next step: review Rx and genetic counseling/testing
genetic basis: CAG expansion of Ch.4 w/ > 40 repeats
Management: Haloperidol for chorea, SSRI for depression, PEG tube for swallowing; goal is to inc. GABA/Ach and dec. dopamine

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3
Q

21y/o w/ h/o progressive dystonia Left upper extremity to the back or left lower extremity. movement include dystonia, myoclonus, and tremor.
Dx?
Next step?
Management?

A

Dx: primary generalized dystonia (DYT1)
Next step: MRI brain
Management: deep stimulation of globes pallidus interna; also benadryl/Benztropine

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4
Q

55y/o w/ asymetric tremor, dec. movement, and rigidity
Dx?
Next step?
Management?

A

Dx: Parkinsons Dz
Next step: MRI brain for other dx
Management: L-dopa/carbidopa

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5
Q

Insidious onset of syndrome w/ gait problems
Dx?
Next step?
Management?

A

Dx: AD spinocerebellar ataxia
Next step: genetic testing
Management: supportive care, rehab

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6
Q

65y/o w/ h/o GI discomfort, now on metoclopramide, has involuntary mouth/facial movement and arching of back and neck
Dx?
Next step?
Management?

A

Dx: Tardive dyskinesia
Next step: D/C metoclopramide, start BNZ +/- baclofen
Management: BNZ, baclofen, Vit E

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7
Q

13y/o obtunded w/ flaccid quadriparesis s/p motor vehicle accident.
Dx?
Next step?
Management?

A

Dx: High cervical spine injury and traumatic brain injury
Next step: MRI of brain and spine; maintain oxygen and perfusion pressure
Management: give IV steroid if w/in 8 hrs to prevent secondary damage from inflammation

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8
Q

18y/o athlete w/ acute brain injury from football associated w/ transient loss of consciousness and seizure. after 2 hrs gets N/V/HA
Dx?
Next step?
Management?

A

Dx: intracerebral bleed –> most likely secondary epidural hematoma
Next step: non-contrast CT
Management: Stabilize and consult neurosurgery

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9
Q

23y/o F w/ acute AMS 24hrs after trauma w/ brief loss of consciousness. Exam shows attention defects, disorganized thinking and fluctuation of symptoms. PE shows generalized hyperreflexia w/ b/l babinski +
Dx?
Next step?

A

Dx: delirium secondary to subarachnoid hemorrhage

Next step: CT head, CBC, CMP, UDS

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10
Q

15y/o boy w/ brief loss of consciousness s/p tackle in football game; mild persistent symptoms > 15 mins after injury
Dx?
Next step?
Management?

A

Dx: Concussion
Next step: CT w/ contrast
Management: observation w/ reassurance

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11
Q

68y/o w/ 30 mins of R hemiparesis, aphasia and h/o HTN, CAD, Afib
Dx?
Next step?
Management?

A

Dx: Acute L MCA ischemic stroke
Next step: Non-contrast CT
Management: thrombolytic therapy if indicated

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12
Q

50 y/o w/ worst HA of life and neck stiffness, left sided weakness and similar HA 2 wks ago. inc BP and CN3 paralysis. blood shows dec Na and ECG changes
Dx?
Next step?
Management?

A

Dx: subarachnoid hemorrhage
Next step: non-contrast CT
Management: Cerebral angiography

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13
Q

22y/o R. horners syndrome and R. hemispheric ischemic stroke s/p minor neck trauma
Dx?
Next step?
Management?

A

Dx: R carotid artery dissection –> stroke
Next step: cerebral angiogram
Management: surgery

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14
Q

23y/o lost consciousness and awoke w/ confusion and urinary incontinence
Dx?
Next step?
Management?

A

Dx: seizure
Next step: BEM (blood labs, EEG, MRI)
Management: NO driving

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15
Q

23y/o w/ repetitive motor behavior
Dx?
Next step?
Management?

A

Dx: complex partial seizure
Next step: BEM (blood labs, EEG, MRI)
Management: NO driving

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16
Q

64y/o w/ acute loss of consciousness w/o warning/provocation or post episodic confusion. 3rd episode of this happening
Dx?
Next step?
Management?

A

Dx: cardiogenic syncope
Next step: cardiac evaluation and ECG
Management: review meds

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17
Q

23y/o suddenly seized in all four limbs while conscious complaining about pain and yelling for help
Dx?

A

Dx: pseudoseizure

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18
Q

24y/o F w/ 12yr h/o unilarteral headache w/ aura
Dx?
Next step?
Management?

A

Dx: migraine
Next step: MRI
Management: +/- Rx

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19
Q

38y/o w/ 10yr h/o daily HA in temples radiating to neck presents different HA 3x in a month over eye w/ N/V. H/o episodic migraine. inc OTC does not help. +occipital pain
Dx?
Next step?
Management?

A

Dx: chronic daily headache (tension + migraine) w/ analgesic rebound and occipital neuralgia
Next step: neuro exam
Management: tape acetaminophen +/- occipital nerve block

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20
Q

67y/o w/ h/o 3 yr memory loss recently on amitryptyline x1mo is now extremely confused + agitated
Dx?
Management?

A

Dx: demential (AD) w/ delirium secondary amitryptyline
Management: ABC, D/C amitriptyline, Rx for dementia

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21
Q

64y/o w/ progressive decline in personality and auditory/visual sleep hallucinations. +EPS ~ parkinsons
Dx?
Next step?
Management?

A

Dx: diffuse lewy body dementia
Next step: MRI brain
Management: Rx for dementia

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22
Q

48y/o w/ progressive gait disorder characterized by sensory ataxia caused by impaired position sense and spasticity. PNS and CNS involvement, including white matter in post cord and pyramidal tracts
Dx?
Next step?
Management?

A

Dx: subacute combined degeneration of spinal cord (Vit B12 def)
Next step: get Vit B12 labs
Management: give IM B12

23
Q

23y/o F w/ L subacute painful loss of vision w/o other systemic symptoms. dec. vision in L eye w/ central scotoma. L afferent pupillary defect w/ dec. L extra ocular muscles
Dx?
Next step?
Management?

A

Dx: optic neuritis
Next step: MRI w/in 2 weeks for optic nerve/other regions
Management: short-course IV methylprednisolone

24
Q

24y/o w/ multiple neurologic symptoms including blurry vision and realized this has happened before
Dx?
Next step?
Management?

A

Dx: MS
Next step: Blood studies, LP, MRI
Management: IV steroids —> immune modulating Rx

25
Q

20y/o w/ multiple neurologic symptoms s/p viral illness 2 wks ago. sudden HA, AMS, CNS dysfxn
Dx?
Next step?
Management?

A

Dx: ADEM
Next step: MRI brain vs. LP (25% develop MS)
Management: IV steroids vs. IVIG vs. Plasmapharesis

26
Q

28y/o w/ 48hr h/o crescendo HA. N/V, and slow response to questions. + kerning sign, nystagmus, and hyperreflexia
Dx?
Next step?
Management?

A

Dx: Viral Meningitis
Next step: CT –> LP
Management: IV ceftriaxone, Vanc, Acyclovir, dexamethasone

27
Q

9mo/o w/ 1 week constipation, poor feeding, weak cry, difficulty sucking/moving arms and legs, hypotension, hypotonia, and hyporeflexia
Dx?
Next step?
Management?

A

Dx: Infantile botulism
Next step: stool/serum culture
Management: ICU for respiratory support —> antitoxin

28
Q

52 y/o w/ weight loss, forgetful, dec concentration, clumsy, withdrawal from friends. NI MMSE, slow w/ answering questions poor coordination of hands hyperreflexic and HIV+
Dx?
Next step?

A

Dx: HIV associated dementia

Next step: Neuropsychological testing, LP, MRI

29
Q

53y/o F w/ 4mo h/o rapidly progressive memory loss, ataxia, mood swings, inappropriate behavior, and dysarthria. abnormal MMSE w/ global abnormalities, moderate dysarthria, and anomia. nystagmus, dysmetria, ataxia, myoclonus, hyperreflexia
Dx?
Next step?
Management?

A

Dx: sporadic CJD
Next step: complete serology, LP, MRI, EEG
Management: supportive

30
Q

58y/o w/ h/o syphilis >20 yrs ago has 3 yr h/o leg pain, loss of balance, impotence and ptosis. exam shows argyll robertson pupils, impaired posterior column and lateral spinothalamic tract. hyporeflexic in legs, sensory ataxia, + romberg
Dx?
Next step?
Management?

A

Dx: Tabes dorsalis
Next step: LP for VDRL
Management: IV penG 2-4M units q4 x10-14days (doxy/ceftriaxone if allergic)

31
Q

25y/o s/p tonic-clonic seizure and 6 mo h/o HA has h/o STD/IVRx. CT shows 2x ring enhancing lesions
Dx?
Next step?
Management?

A

Dx: cerebral toxoplasmosis
Next step: Serum IgM + IgG for toxo/ LP PCR Toxo
Management: Pyrimethamine, sulfadiaine, folinic acid

32
Q

17y/o w/ R frontal HA s/p trauma. no LOC, no improvement w/ tylenol. gets better w/ ice. PE shows non reactive R pupil. CT is normal
Dx?
Next step?

A

Dx: Holmes-Adie pupil

Next step: apply 0.1% pilocarpine to R pupil

33
Q

26y/o obese F w/ blurred vision + HA had 2-3 wk transient graying of vision. CT nl , b/l papilledema
Dx?
Next step?
Management?

A

Dx: inc ICP, likely pseudo tumor cerebri
Next step: LP + Optho eval
Management: If PTC –> high volume LP

34
Q

65y/o w/ HTN, CAD, and 24hr h/o binocular horizontal diplopia w./ R lateral rectus palsy
Dx?

A

Dx: ischemic mononeuropathy of CNVI

35
Q

68y/o w/ R facial paralysis, R ear pain and R sided sensorineural hearing loss. Blisters on erythematous base in R concha, no damage tyrannic membrane
Dx?
Next step?
Management?

A

Dx: herpes zoster oticus (ramsay hunt syndrome)
Next step: tzanck smear, audiogram, CNVII studies
Management: anti-viral Rx

36
Q

30 y/o w/ 2 mo h/o fatigue and ptosis. ptosis improves w/ putting ice water on the eye
Dx?
Next step?
Management?

A

Dx: Myasthenia gravis w/ ptosis
Next step: anti-ACh receptor Ab
Management: pyridostigmine (symptoms) + plasmapharesis

37
Q

63 y/o with episodic positional vertigo w/o hearing loss
Dx?
Next step?
Management?

A

Dx: BPPV
Next step: Dix hall pike
Management: epley maneuver +/- symptomatic

38
Q

64y/o w/ HTN has slowly progressive weakness and stocking glove pattern sensory loss >2mo. normal glucose
Dx?
Next step?
Management?

A

Dx: CIDP
Next step: EMG/NCS
Management: Steroids IVIG

39
Q

25y/o w/ h/o gastroenteritis 5 wks ago presents w/ rapid ascending weakness involving diaphragm. PE shows areflexia, paralysis of legs w/ sensory dz, weakness in arm and swallowing difficulty
Dx?
Next step?
Management?

A

Dx: AIDP (GBS)
Next step: LP for albuminocytologic dissociation
Management: FVC –> intubation

40
Q

30y/o F w/ proximal muscle weakness, skin rash, raynauds, dysphagia, SOB, and arrythmia
Dx?
Next step?
Management?

A

Dx: Dermatomyositis
Next step: skeletal muscle biopsy
Management: immunomodulatory Rx/Cardio-respiratory stabilization

41
Q

64y/o w/ progressive skeletal muscle weakness of BUE/BLE. PE shows pure motor weakness (no sensory loss) + atrophy
Dx?
Next step?
Management?

A

Dx: ALS
Next step: EMG/NCS
Management: immediate repiratory/swollow fxn

42
Q

45y/o RH secretary w/ hypothyroidism has CT syndrome causing her to wake from sleep + Tinel sign
Dx?
Next step?
Management?

A

Dx: R median nerve neuropathy (Carpal tunnel)
Next step: EMG/NCS
Management: Splint + analgesic, rehab, surgery

43
Q

R foot drop in young woman; inability to raise R foot above gravity/ evert laterally
Dx?
Next step?
Management?

A

Dx: common perineal nerve palsy
Next step: EMG/NCS
Management: ankle/foot orthotics, surgery

44
Q

8y/o w/ nocturnal facial twitching. h/o similar nocturnal event 4 yr ago and febrile seizures @1yr/o father had childhood seizures
Dx?
Next step?

A

Dx: pediatric seizure disorder w/ h/o febrile sezures

Next step: BEM (blood labs, EEG, MRI)

45
Q

22mo/o w/ 1 day URI has generalized seizure
Dx?
Next step?
Management?

A

Dx: simple febrile seizure
Next step: determine source (CBC, nasal, LP, UA, CXR)
Management: antipyretics + tx source of fever

46
Q

13 y/o w/ h/o HA has severe HA w/ N/V associated w/ brief prodrome. associated w/ menses
Dx?
Next step?
Management?

A

Dx: pediatric migraine w/o aura (common migraine)
Next step: no diagnostic studies
Management: Nsaid +/- triptan for prophylaxis

47
Q

3y/o w/ proximal muscle weakness, toe walking, calf enlargement. inc CK
Dx?
Next step?
Management?

A

Dx: douchenes muscular dystrophy
Next step: Muscle biopsy +/- peripheral nerve DMD gene
Management: supportive, monitor heart and lungs

48
Q

8 y/o w/ 12 mo h/o motor/phonic tics and concurrent OCD
Dx?
Next step?
Management?

A

Dx: tourrettes
Next step: clinical dx
Management: education and Rx if needed

49
Q

7 y/o w/ nocturnal spell of hemifacial clonus and speech arrest –> secondary tonic clonic. post octal confusion, + FHx
Dx?
Next step?
Management?

A

Dx: Benign rolandic epilepsy
Next step: outpatient EEG
Management: reassurance as will resolve

50
Q

13y/o w/ recurrent seizures, mental retardation, delay. Birth h/o IUGR, cryptochidism, craniofacial dysmorphism, sacral dimple
Dx?
Next step?
Management?

A

Dx: miller-dieker syndrome ~ lissencephaly type1
Next step: MRI brain
Management: symptomatic Rx

51
Q

2 y/o w/ delayed language, abnormal social interaction and abnormal behavior w/ no other problems
Dx?
Next step?
Management?

A

Dx: autism
Next step: audiological evaluation
Management: education + behavior modification

52
Q

43 y/o w/ h/o HA hearing loss and facial paralysis
Dx?
Next step?
Management?

A

Dx: cerebellopontine angle mass (MC acoustic neuroma/meningioma)
Next step: MRI w/ gadolinium
Management: surgery/observation

53
Q

60y/o w/ 20 pack yr smoking hx has 6 wk R frontal temporal HA. + personality change, dec left arm swing, L finger extensor and + L babinski
Dx?
Next step?
Management?

A

Dx: Metastatic brain tumor (lung) in R cerebral hemisphere
Next step: MRI w/ and w/o gadolinium + CXR
Management: corticosteroids/ andticonvulstants

54
Q

NB w/ hypotonia, frog leg, hyporeflexic and fibrillations
Dx?
Next step?
Management?

A

Dx: SMA type 1 (werdnig hoffmans dz)
Next step: SMN1 gene testing
Management: Respiratory support / supportive therapy

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